Accurate Documentation
During my last week in Neurology I treated a lady with a diagnosis of slowly worsening secondary progressive MS. Reason for admission was for a Baclofen trial pump to aid in reducing the spasticity in both her legs. She was initially scheduled for the trial pump approximately two years ago but decided to postpone it in order to try for another child. Since the birth of her last child her MS has significantly worsened. Of the many Objective assessments completed, the Modified Ashworth Scale (MAS) revealed severe spasticity of both LL (all major joints were a 5/5).
After speaking to the pt she was under the impression she was admitted into hospital to not only have a trial but with a view of implanting a permanent subcutaneous Baclofen pump. When told by the doctors that this was probably not going to be the case and she would need to come back in a few months she was very upset. Later on that day I treated her one hour after her initial Baclofen dose and was incredibly surprised to reveal that the MAS showed significant improvement in all major LL joints (0/5 spasticity, apart from her plantarflexors 3/5), this had a huge impact on her functional ability and effectiveness of our treatment session. My clinical supervisor was also a bit angry when hearing what the doctors planned on doing, primarly bc of poor communication and encouraged me to duly document these findings (Baclofen). The next day when assessing the pt prior to treatment the doctors arrived at the pts bed only to reveal they had changed their mind and would now insert a permanent pump due to significant improved functional mobility. The pt was very happy!
On reflection it made me realize to never be complacent with my notes, to be objective at all times and always document clinically important findings (eg Baclofen). This is not only for my benefit but other health personnel will be reading my notes and in fact important decisions are made regarding my notes. If any one else can relate or has any other input I would like to hear.
posted by Christian @ 5:06 PM
2 Comments:
Hi Christian
I found something very similar on my cardio placement. Being on a gen med ward, there was a constant push for patients to be discharged. It was rewarding to read the patients notes from the doctors, and to see that they had taken into account what the allied health team had been doing with the patient and the patients progress.
As a result there was also added importance in the physio being sure that the patient can ambulate INDEPENDENTLY and SAFELY so that discharge can occur. As you have said, more than just other physios read what the physio is doing with the patient, and therefore you need to always be accurate and objective.
I agree and have some serious work to do myself on improving my handwriting (and spelling)...since I don't plan on becoming a doctor!. But honestly it can be rough when you can't make heads nor tails of, often critically important, details from the notes. Just one more thing to add to the list of continual goals in this career.
Post a Comment
Subscribe to Post Comments [Atom]
<< Home